Sleeping Through Detox Poses Hazards

Anesthesia-assisted opioid withdrawal, offered as
quicker and easier than other rapid detoxification methods, was recently found
to be comparable on several measures, but with greater risk for
life-threatening adverse events. A randomized trial comparing anesthesia-, buprenorphine- (Subutex) and clonidine- (Catapres) assisted
heroin detoxification found similarity in withdrawal symptom severity, low
rates of inpatient program completion and high proportion of follow-up opioid-positive urine tests (Collins et al., 2005). While
no detoxification procedure appeared "painless" or to facilitate program
compliance or long-term abstinence, the anesthesia- and buprenorphine-assisted
protocols were superior to the clonidine program in
facilitating the naltrexone (ReVia)
induction to rapidly counter opioid effect. The
anesthesia-assisted protocol was distinct, however, in that three of 35
patients experienced serious adverse events.

One patient developed severe pulmonary edema and aspiration pneumonia
approximately 14 hours after extubation. That patient
subsequently admitted to a history of complicated pneumonia and possible
obstructive sleep apnea; both of which were added to the exclusionary criteria
for potential participants. A second patient who had concealed a history of
bipolar illness developed a mixed bipolar state with suicidal ideation that
necessitated rehospitalization five days after
anesthesia.

The third patient had not disclosed a previous episode of diabetic ketoacidosis during screening and after anesthesia had
uncontrolled glucose serum levels and developed ketoacidosis
two days later. The investigators attributed the falsifying of medical or
psychiatric histories in the screening interviews to patients hoping to be
selected for anesthesia due to their expectation that it would obviate the
severe discomfort of opioid withdrawal.

Costing as much as $15,000 and not covered by health insurance, according to
the investigators, the anesthesia-assisted procedure is promoted to the
well-heeled addict as a means to painlessly sleep through an opioid antagonist induction. The procedure is offered,
however, without good evidence to support efficacy and despite
numerous reports of serious adverse events, according Collins and colleagues
(2005):

The eagerness with which both patients and the public have accepted
claims of success highlights the desperation many patients and families feel
about treating opioid dependence.

To evaluate the safety, tolerability and efficacy of anesthesia-assisted
rapid opioid detoxification, the investigators
compared the procedure to two other withdrawal programs that incorporate naltrexone induction. The study cohort consisted of 106
heroin users meeting DSM-IV criteria
for opioid dependence for at least six months.
Following each procedure, patients received clonidine
to mitigate withdrawal symptoms as well as clonazepam
(Klonopin) and ancillary medications as required.
After hospital discharge, all patients were followed for 12 weeks, receiving naltrexone 50 mg daily and twice-weekly, manual-guided
relapse-prevention psychotherapy. The researchers noted that an anticipated
depot naltrexone formulation is likely to increase
participation in, and success of, such programs, in contrast to the current
poor rate of compliance with oral naltrexone.

Anesthesia was maintained for four to six hours, during which the opioid antagonist nalmefene (Revex) was infused intravenously 4 mg over 30 minutes,
followed by naltrexone 50 mg via nasogastric
tube. In the buprenorphine-assisted protocol, a
single 8 mg sublingual "bridging" dose of this partial opioid
agonist was administered to facilitate a more comfortable naltrexone
induction two days later. Collins and colleagues explained that buprenorphine shortens the time until naltrexone
can be administered and that it has a longer duration of action and less severe
withdrawal than heroin. The initial naltrexone dose
was 12.5 mg, increased to 25 mg on day 3 and then to 50 mg daily.